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OBJECTIVE: In the Netherlands, out-of-hours General Practice Cooperatives (GPCs) increasingly collaborate with Emergency Departments (EDs) to form an Emergency Care Access Point (ECAP). ECAPs aim to decrease the number of low-urgent ED attendances, of which many compromise minor traumatic injuries. In this study, we evaluated the impact of ECAP implementation on the incidence of minor traumatic injuries in the ED.METHODS: We evaluated a total of 2772 ED patients who presented with a minor traumatic injury (categorized into traumatic wounds and isolated extremity injuries) 1 year before and 1 year after ECAP implementation. We compared patient characteristics, throughput, diagnosis, treatment and follow-up before and after ECAP implementation.RESULTS: ECAP implementation was associated with a reduction in ED volume for minor traumatic injuries: -12.4% for isolated extremity injuries (1249 vs. 1094) and -74.6% for traumatic wounds (342 vs. 87). Multivariable logistic regression analysis controlling for patient characteristics showed that ECAP implementation was associated with higher rates of substantial injuries in the ED (OR 1.20, 95% CI = 1.01-1.43), and more patients requiring outpatient follow-up.CONCLUSION: Implementation of an ECAP was associated with a reduction of ED utilization by patients with minor traumatic injuries, traumatic wounds in particular. This healthcare intervention may therefore help to reduce ED utilization for low-urgent complaints.

Hospitals, which play an important role in reducing injuries and casualties, must be prepared for a crowd of people in emergencies. The present study aimed to survey and collect data on the likely behaviours of people under emergency circumstances in hospitals in order to improve emergency response plans in these places. The target population was all individuals present in three hospitals from Tabriz (including patients, companions and treatment staff), and the sample size was 1145. A questionnaire was administered to this population in order to collect the data. The comparison of different groups was performed based on participants' gender and their role. Results showed that, in general, everyone in the surveyed hospitals is more likely to choose a reactive strategy rather than a preventive strategy as well as a cooperative strategy rather than a competitive strategy, and less willing to use lifts during emergencies. Comparing different strategies utilized by different people resulting from ordered logit models revealed that there are significant differences in evacuation strategies between men and women as well as between treatment staff and all respondents. Men were more likely to select a proactive strategy rather than a reactive strategy compared to women. Also, the treatment staff group were more likely to employ a cooperative strategy and less likely to use a competitive strategy compared to other people. In view of the role of hospitals, the results of this study can play a major role in policy-making to predict the behaviour of different individuals in healthcare settings and perform needs assessment to consider the necessary facilities or raining required for different people in various countries.

OBJECTIVE: To estimate the impact of Medicaid expansion on emergency department (ED) wait times. DATA SOURCES: We used 2012–2017 hospital‐level secondary data from the CMS Hospital Compare data warehouse. STUDY DESIGN: We used a state‐level difference‐in‐differences approach to identify the impact of Medicaid expansion on four measures of ED wait times: time before being seen by a provider; time before being sent home after being seen by a provider; boarding time spent in the ED waiting to be discharged to an inpatient room; and the percentage of patients who left without being seen. We compared outcomes in states that expanded Medicaid with those in states that did not expand Medicaid. DATA COLLECTION/EXTRACTION METHODS: Our sample included all US acute care hospitals with EDs in states that did not ever expand Medicaid or that fully expanded Medicaid in January of 2014. PRINCIPAL FINDINGS: Medicaid expansion was associated with a 3.1‐min increase (SE: 0.994, baseline mean: 30.8 min) in the time spent waiting to see an ED provider, a relative increase of 10%. Patients who were eventually sent home after being seen by a provider experienced a 7.5‐min increase (SE: 1.8, baseline mean 142.1 min) in wait time. Boarding time rose by 3.8 min (SE 1.9, baseline mean 111.4 min). The percentage of patients who left without being seen rose by 0.3 percentage points (SE: 0.09, baseline mean 2.0), a relative increase of 15.3%. CONCLUSIONS: This study provides multistate evidence that Medicaid expansion increased ED wait times for patients, indicating that ED crowding may have worsened post‐expansion. Future work should aim to uncover the mechanisms through which insurance expansion increased ED wait times to provide policy direction.

This paper exploits a natural experiment involving self-regulation in the ready-to-eat (RTE) breakfast cereal industry to evaluate how firms respond to entry in light of changes in competition and to estimate the value of brand equity as products are re-positioned. Self-regulation led to a crowding of the product space by forcing differentiated products to become more similar. Among other things we find that products constrained by regulation perform relatively worse than unconstrained products, brand equity specific to a product is tightly linked to existing product positions and does not transfer well to new positions, and that when competition increases, firms reposition to new segments and increase investments on product differentiation. The paper offers a performance based assessment of repositioning and to our knowledge offers the first empirical analysis in the strategy literature that measures in performance terms how repositioning changes the value of brand equity.

The COVID‐19 pandemic has called for and generated massive novel government regulations to increase social distancing for the purpose of reducing disease transmission. A number of studies have attempted to guide and measure the effectiveness of these policies, but there has been less focus on the overall efficiency of these policies. Efficient social distancing requires implementing stricter restrictions during periods of high viral prevalence and rationing social contact to disproportionately preserve gatherings that produce a good ratio of benefits to transmission risk. To evaluate whether U.S. social distancing policy actually produced an efficient social distancing regime, we tracked consumer preferences for, visits to, and crowding in public locations of 26 different types. We show that the United States’ rationing of public spaces, postspring 2020, has failed to achieve efficiency along either dimension. In April 2020, the United States did achieve notable decreases in visits to public spaces and focused these reductions at locations that offer poor benefit‐to‐risk tradeoffs. However, this achievement was marred by an increase, from March to April, in crowding at remaining locations due to fewer locations remaining open. In December 2020, at the height of the pandemic so far, crowding in and total visits to locations were higher than in February, before the U.S. pandemic, and these increases were concentrated in locations with the worst value‐to‐risk tradeoff.

Objective This study investigates the degree to which social connections and social context shape attitudes and behaviors surrounding the COVID-19 pandemic in the United States. Methods In April and August 2020, we surveyed Americans about their social context and asked a range of questions related to the coronavirus and social distancing. Results Social crowding, social networks, and social context are related to support for social distancing policies and compliance with those policies. Conclusion The coronavirus pandemic created hardships;hardships made more difficult by the inability to physically interact with extended family and friends and the inability to find space away from immediate family. This research suggests that understanding compliance with public policies requires attention to interpersonal connections.

This study is among the first to investigate whether patterns of access to basic services could explain the disproportionately severe impact of COVID-19 in slums. Using geolocated containment zones and COVID-19 case data for Mumbai, India?s most populous city, we find that cases and case fatality rates are higher in slums compared to formal residential buildings. Our results show that access to toilets for men is associated with lower COVID-19 prevalence. However, the effect is opposite in the case of toilets for women. This could be because limited hours for safely using toilets and higher waiting times increase risk of exposure, and women and children sharing toilet facilities results in crowding. Proximity to water pipelines has no effect on prevalence, likely because slumdwellers are disconnected from formal water supply networks. Indoor crowding does not seem to have an effect on case prevalence. Finally, while police capacity ? measured by number of police station outposts ? is associated with lower prevalence in non-slum areas, indicating effective enforcement of containment, this relationship does not hold in slums. The study highlights the urgency of finding viable solutions for slum improvement and upgrading to mitigate the effects of contagion for some of the most vulnerable populations. This article is protected by copyright. All rights reserved.

Time-based targets for ED length of stay were introduced in England in 2000, followed by the rest of the UK, Canada, Ireland, New Zealand, and Australia after ED crowding was associated with poor quality of care and increased mortality. This systematic review evaluates qualitative literature to see if ED time-based targets have influenced patient care quality. We included 13 studies from four countries, incorporating 617 interviews. We conclude that time-based targets have impacted on the quality of emergency patient care, both positively and negatively. Successful implementation depends on whole hospital resourcing and engagement with targets.

Hitchhikers (phoretic organisms) identify their vehicles using species-specific visual, chemical and vibrational cues. However, what factors influence their choice between vehicles of the same species has rarely been investigated. Hitchhikers must not only avoid overcrowded vehicles but may also need to travel with conspecifics to ensure mates at their destination. Hence, a trade-off between overcrowding and presence of conspecifics likely determines the choice of a vehicle especially when destination sites are distant, ephemeral and unique. Here, we investigate whether a trade-off between the presence of conspecifics versus overcrowding by conspecifics or heterospecifics on a vehicle affects hitchhiker choice. We also investigate the sensory modality responsible for this choice. We experimentally examine these questions using a phoretic nematode community (containing plant- and animal-parasitic taxa) obligately associated with a brood-site pollination mutualism. In this model system, nematodes co-travel with conspecifics and heterospecifics on pollinators as vehicles, between ephemeral plant brood sites to complete their developmental life cycle. In this system, hitchhiker overcrowding has proven negative impacts on vehicle and plant fitness. We expected nematodes to respond to conspecifics and heterospecific density on offered vehicles when making their choice. We found that animal-parasitic nematodes preferred vehicles containing some conspecifics within a certain density range. However, plant-parasitic nematodes preferentially boarded vehicles that were devoid of conspecifics or had few conspecifics. Plant parasites that preferred empty vehicles likely hitchhiked in pairs. Both nematode types employed volatile cues to discriminate between vehicles with different conspecific nematode densities. Our results suggest that vehicle overcrowding by conspecifics, most likely, guaranteed access to mates at the destination determined hitchhiker choice. Surprisingly, and contrary to our expectations, plant- and animal-parasitic nematodes did not respond to heterospecific crowding on vehicles and did not discriminate between vehicles with different heterospecific nematode densities. The reason for this lack of response to heterospecific presence is unknown. This study not only shows that phoretic organisms use different strategies while choosing a vehicle but also confirms that density-dependent effects can ensure the stability and persistence of phoretic interactions in a mutualism by balancing overcrowding against reproductive assurance.

OBJECTIVE The association between ED crowding and mortality has been established internationally, but not in New Zealand. The aim was to determine which measures of crowding were associated with mortality for new patients presenting to New Zealand EDs. The primary outcome was mortality for patients within 7 days of arrival in the ED. METHODS This was a retrospective cohort study, using administrative data from 2006 to 2012. The crowding conditions at the time of presentation of each patient were recreated. Multivariable Cox proportional hazard modelling was used to determine the probability of death within 7 days of the presentation to ED. Each crowding measure was added independently to the optimum mortality model to determine how each crowding metric influenced the model. RESULTS Twenty-five of 28 (89%) eligible acute hospitals in New Zealand were included, with 5 793 767 ED visits by 2 214 865 individuals. Seven-day mortality was higher for patients arriving at times when there was more than 10% hospital access block (hazard ratio [HR] 1.10, 95% confidence interval [CI] 1.05, 1.17) or non-compliance with the 4-h emergency access target (HR 1.07, 95% CI 1.01, 1.12). ED occupancy did not influence the model importantly, while the number of arrivals in the previous 6 h was associated with lower mortality (HR 0.90, 95% CI 0.84, 0.97). CONCLUSION Access block had the strongest association with 7-day mortality. That ED occupancy and the number of arrivals were not associated with increased mortality suggests that system issues related to long ED stays may be most important in the link between ED crowding and mortality.

Lepeophtheirus salmonis is an ectoparasite causing economic concerns in Atlantic salmon farming. Salmon lice infestation management methods can be stressful and impact fish welfare. This work investigated the stress effect on the attachment of L. salmonis copepodids to Atlantic salmon through two approaches: (a) handling by netting and air exposure (acute stress), and (b) crowding with restricted surface access in a tank (chronic stress). In the first experiment, we compared the number of attached L. salmonis and cortisol levels between a group of handled salmon and a control group. In the second experiment, a group of densely packed salmon was compared to a control group based on the number of attached copepodids, cortisol levels and neutrophil:lymphocyte ratios. Handled salmon showed significantly higher plasma cortisol levels (p .05). The neutrophil:lymphocyte ratio was significantly higher (p = .0014) in the densely packed salmon than in the control salmon. Handling salmon increased their risk of infestation by L. salmonis. This has implications for reinfestation rates following delousing treatments in commercial salmon aquaculture, which often involve crowding and handling salmon.

Objective: ED avoidance strategies including In-Event Health Service (IEHS) processes during mass gathering events (MGEs), such as 'Schoolies week', may be important for EDs, ambulance services, the local population, and attendees. The aim of the present study was to provide a longitudinal description of emergency care requirements for young adults (16-18 years old); focussing on the impact of the Schoolies MGEs. Methods: This retrospective observational study included youth (16-18 years) presentations made (i) to local public EDs during Schoolies week in 2008-2014 and (ii) to local EDs over a 3-week period (pre, during, post-Schoolies week) and the IEHS in 2015 and 2016. Descriptive and inferential statistics were undertaken. Results: Youth presentations (n = 4256) were included. Presentation rates/1000 fluctuated over time (range 6.2-21.2). The IEHS provided care for 167 and 288 youth during 2015 and 2016 Schoolies week, respectively. Demographic factors (gender, age, region domiciled) and episode of care factors (time of presentation, mode of arrival, urgency, time to triage, time to be seen by a clinician and length of stay) between 2008 and 2016 varied by year. Toxicology (alcohol and other drugs), trauma, and mental health concerns were the most common diagnoses. Conclusions: The IEHS, operational during Schoolies, appeared to reduce pressures on local EDs by offering rapid, targeted care for potentially vulnerable youth; decrease requirements for hospital transport and minimise impacts on care provision for the local community. Given increases in ED crowding and pressures on ambulance services, such care models may be worth considering for other types of MGEs and in other locations.

Habitat loss is one of largest threats to the persistence of large carnivore populations. However, because most large carnivores are long‐lived, cryptic and wide‐ranging, few studies examine the demographic consequences of habitat loss, and the resultant crowding that ensues, on these species. We used long‐term data to examine the demographic responses of an African lion (Panthera leo) population to flooding‐induced habitat loss in a seasonal wetland, the Okavango Delta, during a transition from low to high annual flooding patterns. We found that intraspecific competition reduced cub survival and that this effect was exacerbated by habitat loss and consequent crowding. The proportion of cubs recorded in the population also declined as crowding increased, and both the survival of cubs and proportion of cubs recorded declined as prey abundance decreased. Apparent sub‐adult survival declined with increasing pride size, but this likely reflects emigration rather than mortality. Adult survival remained relatively constant throughout the study period, a population response which is important in buffering populations against short‐term fluctuations in ecological conditions. As many large carnivore populations face future habitat loss, it is important that we understand the demographic consequences of habitat loss in order to better mitigate its effects in the future.

Crowding in emergency departments (EDs) is a concern for hospital administrators, emergency providers, and patients. Many factors contribute to crowding, including variable patient volume and acuity along with contributing hospital factors such as inadequate nursing support and insufficient inpatient beds resulting in prolonged ED boarding times.1 In order to better study and define characteristics indicative of crowding, the National Emergency Department Overcrowding Study (NEDOCS) established a standardized and validated scoring system to quantify crowding in an academic setting.2 Although individual components attributed to crowding and patient satisfaction have been studied,3-5 including studies utilizing the NEDOCS score in relation to patient satisfaction,6 none to our knowledge have investigated the Press Ganey Associates, Inc (PGA) surveys and NEDOCS scores.

Using a large database of US institutional investors’ trades in the equity market, this paper explores the effect of simultaneous executions on trading cost. We design a Bayesian network modelling the inter-dependencies between investors’ transaction costs, stock characteristics (bid-ask spread, turnover and volatility), meta-order attributes (side and size of the trade) and market pressure during execution, measured by the net order flow imbalance of investors meta-orders. Unlike standard machine learning algorithms, Bayesian networks are able to account for explicit inter-dependencies between variables. They also prove to be robust to missing values, as they are able to restore their most probable value given the state of the world. Order flow imbalance being only partially observable (on a subset of trades or with a delay), we show how to design a Bayesian network to infer its distribution and how to use this information to estimate transaction costs. Our model provides better predictions than standard (OLS) models. The forecasting error is smaller and decreases with the investors' order size, as large orders are more informative on the aggregate order flow imbalance (R2 increases out-of-sample from -0.17% to 2.39% for the smallest to the largest decile of order size). Finally, we show that the accuracy of transaction costs forecasts depends heavily on stock volatility, with a coefficient of 0.78.

OBJECTIVE To identify opportunities for directors of emergency medicine (DEMs) to lead change efforts to address ED crowding and access block. METHODS DEMs were surveyed about their beliefs about, barriers to, and enablers of solutions to ED crowding and access block. RESULTS Key barriers were insufficient resources, entrenched hospital culture, and lack of political will to address ED crowding and access block. Key enablers were developing hospital-wide understanding of the problems, developing a supportive hospital culture, and improved engagement by hospital executive. CONCLUSION Addressing the political and cultural forces that sustain ED crowding and access block are key adaptive challenges requiring DEM leadership.

This article employs a household survey of low-income working-class households conducted in Tokyo in 1930 to investigate nutritional attainment levels and the relationship between calorie intake and morbidity. We find that the daily calorie intake was 2,118 kcal per adult male equivalent, high enough to satisfy the energy requirements for moderate physical activity. Richer households purchased more expensive calories mainly by substituting meat and vegetables for rice. We find negative associations between morbidity and income and crowding, but no significant associations for nutrition, tentatively suggesting that income and crowding were more important for morbidity in 1930 Tokyo than nutrition.

Background/objectives Atopic dermatitis (AD) is the most common skin disease of childhood and is often more severe in African American than white children. The reason for this disparity is unknown, but recent research indicates that it may be due to a combination of environmental and genetic factors. The objective of this article was to explore the relationship between measures of structural racism and residential segregation within pediatric AD. Methods An in-office, online survey consisting of 58 questions spanning 5 domains (demographics, in-home crowding, community crowding, air quality, and litter) was administered to a convenience sample of 201 pediatric AD patients (age 0-18 years). Survey data were geocoded and linked to a measure of structural racism (ie, residential segregation). Results African American children were more likely to live in rented homes, be in lower income families, have caregivers with lower educational attainment, and be exposed to tobacco smoke. The same factors that were associated with worse AD severity in this study were also found in published literature, emphasizing the role of social determinants of health and racial differences in AD severity. Additionally, this study found that living in highly segregated communities was more likely to be associated with severe AD in African American children. Conclusions Consistent with reported literature, socioeconomic status, race, and the physical environment appear to affect AD severity. This investigation adds structural racism as an important community characteristic that likely has significant effects on AD severity for African American Children.

Terrestrial animals are negatively affected by habitat loss, which is assessed on a landscape scale, whereas secondary effects of habitat loss, such as crowding, are usually disregarded. Such impacts are inherently hard to address and poorly understood, and there is a growing concern that they could have dire consequences. We sampled birds throughout a deforestation process to assess crowding stress in an adjacent habitat remnant in the southern Brazilian Atlantic Forest. Crowding is expected of highly mobile taxa, especially given the microhabitat heterogeneity of Neotropical forests, and we hypothesized that the arrival of new individuals or species in refuges shifts assemblage patterns. We used point counts to obtain bird abundances in a before-after-control-impact design sampling of a deforestation event. Temporal changes in taxonomic and functional diversity were examined with metrics used to assess alpha and beta diversity, turnover of taxonomic and functional similarity, and taxonomic and functional composition. Over time increased abundance of some species altered the Simpson index and affected the abundance-distribution of traits in the habitat remnant. Taxonomic composition and functional composition changed in the remnant, and thus bird assemblages changed over time. Taxonomic and functional metrics indicated that fugitives affected resident assemblages in refuges, and effects endured2 years after the deforestation processes had ceased. Dissimilarity of taxonomic composition between pre- and postdeforestation assemblages increased, whereas functional composition reverted to preimpact conditions. We found that ecological disruptions resulted from crowding and escalated into disruptions of species' assemblages and potentially compromising ecosystem functioning. It is important to consider crowding effects of highly mobile taxa during impact assessments, especially in large-scale infrastructure projects that may affect larger areas than is assumed.Efectos del Amontonamiento debido a la Pérdida del Hábitat sobre los Patrones de Ensamblaje de las Especies Resumen Los animales terrestres se ven afectados negativamente por la pérdida del hábitat, la cual es evaluada con una escala de paisaje, mientras que los efectos secundarios de la pérdida del hábitat, como el amontonamiento, suelen ser ignorados. Dichos impactos son inherentemente difíciles de tratar y su entendimiento es muy pobre, además de que existe una preocupación creciente por las posibles consecuencias graves que podrían tener. Muestreamos aves durante un proceso de deforestación para evaluar el estrés por amontonamiento en un hábitat remanente contiguo a la parte sur del Bosque Atlántico Brasileño. Se espera que el amontonamiento ocurra en taxones con mucha movilidad, especialmente en el caso de los heterogéneos bosques Neotropicales, por lo que nuestra hipótesis consistió en suponer que la llegada a los refugios de nuevos individuos o especies modifica los patrones de ensamblado. Usamos el conteo por puntos para obtener la abundancia de las aves en un diseño de muestreo de antes-después-control-impacto de un evento de deforestación. Examinamos los cambios temporales en la diversidad taxonómica y funcional con medidas usadas para evaluar la diversidad alfa y beta, la rotación de la similitud taxonómica y funcional y la composición taxonómica y funcional. Con el tiempo, el incremento en la abundancia de algunas especies alteró el índice Simpson y afectó la abundancia y distribución de los caracteres en el hábitat remanente. La composición taxonómica y la composición funcional cambiaron en el hábitat remanente, por lo que los ensamblajes de aves cambiaron con el tiempo. Las medidas taxonómicas y funcionales indicaron que los individuos fugitivos afectaron a los ensamblajes de residentes en los refugios y sus efectos perduraron más de dos años después de que el proceso de deforestación había culminado. La disparidad de la composición taxonómica entre los ensamblajes antes y después de la deforestación incrementó, mientras que la composición funcional se revirtió a las condiciones previas al impacto. Encontramos que las perturbaciones ecológicas resultaron en el amontonamiento de especies y después escalaron hasta llegar a ser perturbaciones en el ensamblaje de las especies y potencial empobrecimiento del funcionamiento del ecosistema. Es importante considerar los efectos del amontonamiento de los taxones con mucha movilidad durante las evaluaciones de impacto ambiental, especialmente para proyectos con infraestructuras a gran escala que podrían afectar a un área mayor a la supuesta inicialmente.景观尺度的评估表明生境丧失对陆地动物造成了负面影响, 但生境丧失的次级影响 (如拥挤) 却常常遭到忽视。这些影响本身难以研究, 也少有理解, 人们目前越来越担心它们会产生可怕后果。本研究对森林砍伐过程中的鸟类进行取样调查, 评估了巴西大西洋森林南部地区相邻生境碎片的拥挤压力。我们推测移动能力强的类群可能会发生拥挤, 特别是考虑到新热带森林的微生境异质性, 我们还猜测避难所中新到达的个体或物种会改变群聚格局。本研究用点计数法来获得了一次森林砍伐事件的前后控制影响设计抽样的鸟类丰度, 并利用评估α和β多样性、类群相似性和功能相似性更新、类群组成和功能组成的指标分析了类群多样性和功能多样性随时间的变化。结果表明, 随着时间推移, 某些物种的丰度增加改变了 Simpson 指数, 还影响了残余生境一些性状的丰度分布。此外, 类群组成和功能组成也会发生变化, 鸟类群聚随之改变。类群和功能的指标表明, 避难所中避难的鸟类影响了定居物种的群聚, 并且这种影响在森林砍伐过程停止两年后仍然存在。森林砍伐前后类群组成的差异越来越大, 而功能组成则会恢复到干扰前的状态。我们还发现, 拥挤导致的生态破坏会进一步使物种群聚受影响、生态系统功能发生退化。在评估高度移动的类群所受影响时考虑拥挤效应十分重要, 在影响可能超出预期地区的大型基础设施建设项目中尤其如此。【翻译: 胡怡思; 审校: 聂永刚】.

Response of endophytic fruit fly species (Tephritidae) to larval crowding is a form of scramble competition that may affect important life history traits of adults, such as survival and reproduction. Recent empirical evidence demonstrates large differences in adult life history traits, especially longevity, among Mediterranean fruit fly (Ceratitis capitata; "medfly") biotypes obtained from different regions of the world. However, whether the evolution of long lifespan is associated with response to stress induced by larval crowding has not been fully elucidated. We investigated, under constant laboratory conditions, the response of a short- and a long-lived medfly biotypes to stress induced by larval crowding. Survival and development of larvae and pupae and the size of resulting pupae were recorded. The lifespan and age-specific egg production patterns of the obtained adults were recorded. Our findings reveal that increased larval density reduced immature survival (larvae and pupae) in the short-lived biotype but had rather neutral effects on the longed-lived one. Only larvae of the long-lived biotype were capable of prolonging their developmental duration under the highest crowding regime to successfully pupate and emerge as adults. Response of emerging adults to larvae crowding conditions was similar in the two medfly biotypes. Those individuals emerging from high larval density regimes had reduced longevity and fecundity. Long-lived biotype individuals, however, appeared to suffer a higher cost in longevity compared with the short-lived one. The importance of our findings to understand the evolution of long lifespan is discussed.

The WHO recommends exclusive breastfeeding for the first 6 months of life. However, the transition of the infants' diet to partial breastfeeding with the addition of animal milks and/or solids typically occurs earlier than this. Here, we explored factors associated with the timing of an early transition to partial breastfeeding across seven sites of a birth cohort study in which twice weekly information on infant feeding practices was collected. Infant (size, sex, illness and temperament), maternal (age, education, parity and depressive symptoms), breastfeeding initiation practices (time of initiation, colostrum and pre‐lacteal feeding) and household factors (food security, crowding, assets, income and resources) were considered. Three consecutive caregiver reports of feeding animal milks and/or solids (over a 10‐day period) were characterized as a transition to partial breastfeeding, and Cox proportional hazard models with time (in days) to partial breastfeeding were used to evaluate associations with both fixed and time‐varying characteristics. Overall, 1470 infants were included in this analysis. Median age of transition to partial breastfeeding ranged from 59 days (South Africa and Tanzania) to 178 days (Bangladesh). Overall, higher weight‐for‐length z‐scores were associated with later transitions to partial breastfeeding, as were food insecurity, and infant cough in the past 30 days. Maternal depressive symptoms (evaluated amongst 1227 infants from six sites) were associated with an earlier transition to partial breastfeeding. Relative thinness or heaviness within each site was related to breastfeeding transitions, as opposed to absolute z‐scores. Further research is needed to understand relationships between local perceptions of infant body size and decisions about breastfeeding.

The COVID-19 pandemic has produced significant changes in emergency medicine patient volumes, clinical practice, and has accelerated a number of systems-level developments. Many of these changes produced efficiencies in emergency care systems and contributed to a reduction in crowding and access block. In this paper, we explore these changes, analyse their risks and benefits and examine their sustainability for the future to the extent that they may combat crowding. We also examine the necessity of a system-wide approach in addressing ED crowding and access block.

CONTEXT The reduction in inappropriate utilization of hospitals' emergency departments (EDs) is usually an important objective of primary health care (PHC) reforms. Existing literature provides mixed evidence on the effectiveness of PHC reforms in reducing inappropriate utilization of ED. We assess whether the specific PHC reforms ongoing in Portugal since 2005, and in particular the creation of family health units (FHUs), were successful in reducing inappropriate utilization of EDs and provide a contribution to the debate of which PHC models contribute to reduce overuse of EDs. METHODS We use patient-level data of 117 391 ED visits from two nonurban hospitals in Portugal to estimate a multivariate logistic regression that assesses the impact of different PHC models on inappropriate ED visits. Patients in our sample had four different models of PHC provision: the new FHU type A or type B and the old personalized health care units (PHUs), with or without a specific family physician assigned. RESULTS The percentage of episodes that correspond to appropriate visits to the ED is 2% higher for patients enrolled in an FHU type B and 0.8% higher for users of FHU type A, when compared with users enrolled in PHU. Having an assigned family physician increases appropriate use of the ED by 1%. CONCLUSION Portugal's PHC reform was successful in reducing inappropriate utilization of EDs.

Incentive programs to encourage landowners to protect habitat should be carefully designed to avoid motivation crowding: basically, replacing intrinsic reasons such as a land ethic with extrinsic ones like payments. Little research on motivation crowding tests real programs, and no such work has been done in Canada. We surveyed farmers in Nova Scotia in 2017 to explore whether participation in a new incentive program called Wood Turtle Strides, or knowledge about a similar incentive program potentially available in the future, would alter reported motivations to use riparian setbacks and buffers. Motivations to use setbacks or buffers were heavily intrinsic across all four survey cohorts: wildlife stewardship and sacrifice motivated actions more than social pressures. We were not able to statistically test for motivational crowding due to low program uptake and thus post-program survey responses, but there was no evidence of second-hand crowding: farmers being motivated by hearing about a program in an adjacent jurisdiction. Findings point to the significance of wildlife stewardship for many farmers, and persistent resistance to conservation among others, as well as a risk of low additionality. More post-program research is necessary to fully understand the program's net impact on motivations and conservation.

This study is motivated by the need to understand how the rise of medium‐scale farms in Africa is affecting small‐scale farm households. Survey evidence over the past decade has shown a dramatic rise in the prevalence of ‘medium’ sized farms between 5 and 100 hectares, but smaller farms still constitute the vast majority of farms and rural households. Prior evidence highlights a co‐evolution between the concentration of landholdings, surplus production volumes, and entry of larger traders into the market. Whether these changes tend to impact on smallholders negatively, crowding them out of markets, for example, or positively, potentially opening new marketing channels, is an empirical question. Using a multi‐stage model for maize market participation in Zambia, we find that in areas where medium‐scale farms are growing, even the smaller farms are becoming more likely to sell maize, more likely to sell to the private sector, more likely to sell to larger traders, and expected sales amongst sellers are higher. On balance, the growth of medium‐scale farms and large‐scale traders seems to have positive spillover effects on nearby smallholder marketing options.

Background Melanoma, particularly nevoid melanoma, can masquerade as benign. Helpful differentiating features include nuclear pleomorphism, atypia, prominent nucleoli, absent maturation, and increased mitotic figures. These can be subtle and easily missed unless carefully sought. Thus, the "puffy shirt appearance" concept was born from a Seinfeld episode in which the namesake character unintentionally agreed to wear a pirate-like puffy shirt. Consequently, he found himself out of place, sporting an outfit with "too much shirt in too little space". Similarly, at low-power, nevoid melanoma appears to have "too many cells in too little space". This is more pronounced and easier to appreciate when there is an associated nevus, where crowded, subtly malignant melanocytes stand out from the evenly distributed, more spaced out benign melanocytes. Methods Twelve practicing dermatopathologists familiar with the puffy shirt concept in the context of melanoma were surveyed. Results Hundred percent of participants found it most helpful as a triaging tool, prompting additional work up including higher magnification evaluation, additional levels, consultation, and/or immunohistochemistry. Conclusions The crowded cells in the "puffy shirt appearance" catch the eye and should provoke a more thorough inspection of the lesion. This sign is not pathognomonic for melanoma, but prompts more careful evaluation and helps prevent misdiagnosis.

BackgroundIn England, nearly one child in ten lives in overcrowded housing. Crowding is likely to worsen with increasing population size, urbanisation, and the ongoing concerns about housing shortages. Children with behavioural difficulties are at increased risk of mental and physical health problems and poorer employment prospects.ObjectiveTo test the association between the level of crowding in the home and behavioural problems in children, and to explore what factors might explain the relationship.MethodsMothers of 2576 children from the Southampton Women's Survey population‐based mother‐offspring cohort were interviewed. Crowding was measured at age 2 years by people per room (PPR) and behavioural problems assessed at age 3 years with the Strengths and Difficulties Questionnaire (SDQ). Both were analysed as continuous measures, and multivariable linear regression models were fitted, adjusting for confounding factors: gender, age, single‐parent family, maternal education, receipt of benefits, and social class. Potential mediators were assessed with formal mediation analysis.ResultsThe characteristics of the sample were broadly representative of the population in England. Median (IQR) SDQ score was 9 (6‐12) and PPR was 0.75 (0.6‐1). In households that were more crowded, children tended to have more behavioural problems (by 0.20 SDQ points (95% CI 0.08, 0.32) per additional 0.2 PPR, adjusting for confounding factors). This relationship was partially mediated by greater maternal stress, less sleep, and strained parent‐child interactions.ConclusionsLiving in a more crowded home was associated with a greater risk of behavioural problems, independent of confounding factors. The findings suggest that improved housing might reduce childhood behavioural problems and that families living in crowded circumstances might benefit from greater support.

Crowding, the disrupted recognition of a peripheral target in the presence of nearby flankers, sets a fundamental limit on peripheral vision perception. Debates persist on whether the limit occurs at early visual cortices or is induced by top-down modulation, leaving the neural mechanism for visual crowding largely unclear. To resolve the debate, it is crucial to extract the neural signals elicited by the target from that by the target-flanker clutter, with high temporal resolution. To achieve this purpose, here we employed a temporal response function (TRF) approach to dissociate target-specific response from the overall electroencephalograph (EEG) recordings when the target was presented with (crowded) or without flankers (uncrowded) while subjects were performing a discrimination task on the peripherally presented target. Our results demonstrated two components in the target-specific contrast-tracking TRF response-an early component (100-170 ms) in occipital channels and a late component (210-450 ms) in frontoparietal channels. The late frontoparietal component, which was delayed in time under the crowded condition, was correlated with target discrimination performance, suggesting its involvement in visual crowding. Granger causality analysis further revealed stronger top-down modulation on the target stimulus under the crowded condition. Taken together, our findings support that crowding is associated with a top-down process which modulates the low-level sensory processing and delays the behavioral-relevant response in the high-level region.

Thriving at work is a positive psychological state that captures employees' joint experience oflearning and vitality. Building on the socially embedded model of thriving , we first propose thepositive relationship between leader-member exchange (LMX) and retail employees' thriving atwork. We then explore store spatial crowding as a contextual constraint on this relationship. Tobetter reveal this contextual impact, we further contend that team negative affective tone medi-ates the cross-level moderating effect of store spatial crowding on the LMX–thriving linkage.Using two-wave survey data collected from retail employees and their store managers across89 stores of a grocery retail chain, we found empirical evidence on our multilevel-mediatedmoderation model. This study highlights the importance of considering wider contextual fea-tures as boundary conditions to thriving. Our results suggest theoretical modifications to theexisting thriving model and offer implications on the practical interventions that retailing organi-zations can take to develop a thriving workforce.

Background The house mouse (Mus musculus) is a cosmopolitan rodent that has become adapted to living in close association with humans and is considered a serious pest because it poses a risk to human health, and causes economic losses due to food and crop consumption and damage to buildings. Its control in livestock farms is achieved mainly through the application of anticoagulant rodenticides, but the effect of these compounds is limited due to the presence of resistant individuals and aversive behaviours. A potential alternative method is the use of chemical signals to reduce rodent reproductive success. In this study, we assessed the effects of odours from an unfamiliar male, 17β-oestradiol, overcrowding, cat urine and 2,5-dihydro-2,4,5-trimethylthiazoline (TMT) on the reproductive success of laboratory Mus musculus females. Results According to the generalized linear mixed models, cat urine odour increased the proportion of abortions per female, unfamiliar male odour decreased the mean number of offspring born per female, and TMT had an overall negative effect on mean offspring production at birth and at weaning. The other odours had no significant effects on reproductive success. Conclusions TMT seems to be the best candidate for population control because it caused a decrease in the mean number of offspring born and the mean number of live offspring at weaning. TMT also has the advantage of being available in commercial forms. To be useful for rodent management in field conditions, these results should be confirmed using wild house mice females. © 2019 Society of Chemical Industry.